Early screening helps

Autism is not as rare as it is presumed to be nor is it a western phenomenon. Early detection can lead to minimising the damage, says LALITHA SRIDHAR.

AUTISM, in so many ways, is still a medical puzzle. Fortunately, research is pressing ahead to fill in the missing pieces. Till recently, in most cases, detection and diagnosis came about only around the time the child went to school and found it difficult to cope with normal teaching methods.

Pioneering research is being conducted with a focus on early detection at the Autism Research Centre in Cambridge University, U.K.

Co-director Dr Simon Baron-Cohen was in Chennai recently to discuss the latest developments at the Institute of Remedial Intervention Services (IRIS : www.autismindia.com).

Dr. Baron-Cohen and his team have developed a Checklist for Autism in Toddlers (CHAT) which lists a series of easily answerable questions (see box item) directed at parents and paediatricians, enabling convincing diagnosis as early as 18 months. Here he explains the defining parameters and concerns behind his research and the benefits of early diagnosis: "Some doctors still believe autism is rare ("one in a million") whereas classic autism occurs in one child in every thousand, and if one includes the various shades of autism (including Asperger Syndrome) the rate is as high as one child in every 200. Some doctors still believe that autism is just a middleclass, western problem, whereas autism has been found in every culture and social strata. But it is still the case that many people do not know how to recognise autism or cannot obtain the help that should be theirs by right.

"When autism affects a child, his or her social life is hit. Making friends, chatting, even recognising another person's feelings, can become difficult. Autism not only interrupts social development, but slows down language development, so that the child is not saying even single words by the time he or she is two years old. Autism affects boys far more than girls.

"If a child shows social and communication difficulties, and repetitive and obsessional behaviour, from early in development, this warrants a diagnosis of an autism spectrum condition. If there is additional language delay, it is called autism. If there is additional retardation, it is also autism. If there is no language delay or retardation, it is called Asperger Syndrome. If just some but not all of the core symptoms are present, this might be described as "autistic features", or PDD (Pervasive Developmental Delay). Of these conditions, autism is the clearest to recognise.

"It has been established that autism is caused by brain abnormalities. Our own research has employed the newest technology of brain imaging (MRI), revealing that when the normal person sees another person's facial expression, the amygdala (deep in the limbic system of the brain) responds strongly. When a person with autism looks at another person's facial expression, the amygdala remains silent. This malfunction of the social and emotional centre in the autistic brain is itself thought to be the result of genetic factors, and leaves the child socially isolated and detached.

"But despite the lack of 'social intelligence', people with autism can have any level of 'non-social' intelligence. There are many high-functioning cases, including one man who has recently won the equivalent of the Nobel Prize in mathematics. This man, suffering from the form of autism known as Asperger Syndrome (AS), is a perfect example of how different aspects of intelligence can develop independently of one another. Other people with AS have managed to become scientists, computer specialists, or work in other factual occupations, even while the basics of social sensitivity may be beyond them.

"Although the dominant scientific theory of the cause of autism is a genetic theory, there are some environmental theories also. These remain controversial. The most controversial of these is that autism can be caused by the MMR (measles, mumps and rubella) vaccination. This is currently causing a public health panic in the U.K., even though the evidence for this link is not strong.

"In the 10-minute CHAT test, the doctor simply checks if the child spontaneously points things out for others, using the index finger to share an experience and interact socially. The doctor also checks if the child has spontaneously begun to pretend during play (for example, imagining a pen is an aeroplane flying through the air). Children with autism point far less to communicate, and do not often think about imaginary meanings.

"We screened 16,000 children aged 18 months old, using CHAT. All of these children lived in a defined geographical region in the south of England. Of these, only 12 children failed the key items on the CHAT on two successive administrations. When they were invited in for a full diagnostic assessment at Guys Hospital, London, 11 of the 12 children had an autism spectrum diagnosis. The CHAT therefore has high specificity: if a child fails on this checklist, he or she has a very high risk (over 90 per cent) of going on to receive a diagnosis of autism. But CHAT has low sensitivity, because it misses cases of autism too. So far, it is the most thoroughly researched tool for early screening of autism, and using it leads to genuine cases being identified who would otherwise be missed.

"Picking up that a child has autism in infancy means that treatment has a better chance of shaping brain development and may lead to a better outcome."

Equestrian skills

Ann Galloway is a Grade I instructor of the noted British Horse Academy and has been a trainer with over two decades of experience behind her. Teaching potential jockeys at the Chennai Equestrian Academy, she has also developed a programme for children with special needs based on her varied teaching experience which led to the insight that differently abled individuals find, "Horses are like legs under them. It gives them the feeling of being able to move about on their own, a sensation that cannot be replicated on, say, a wheelchair. Often autistic and spastic children are highly strung and being around animals is a calming and relaxing experience."

So far nine children, from ages four to 15, have been participating in this unique effort. The horses used with the special children are chosen for their quiet and peaceful nature. They also have to be short and not very big so a child climbs easily and is not intimidated by the size of the creature. Ramamani Ravi, mother of Niranjan, the oldest student at 14, explains: "Animals have been recognised as co-therapists. They are known to have a sixth sense and feel the rider and respond to his needs." The initial classes are devoted to establishing a rapport between the horse and its rider. Ms. Galloway deals with one child at a time "for individual concentration" and introductions involve "patting and walking with the animal." Parents are encouraged to stroll along so that when the child climbs on for the first time he/she doesn't feel threatened. Many of the children, depending on the degree of disability, may not be able to canter or trot on their own but all display significant positive changes, both physical (in terms of posture) and mental (with a decline in mood swings).

* * *

The CHAT

Section A (for parents):

1. Does your child enjoy being swung, bounced on your knee, etc? Yes/No

2. Does your child take an interest in other children? Yes/No

3. Does your child like climbing on things, such as up the stairs? Yes/No

4. Does your child enjoy playing peek-a-boo/hide-and-seek? Yes/No

5. Does your child ever pretend, for example, to make a cup of tea using a toy cup and teapot, or pretend other things? Yes/No

6. Does your child ever use his/ her index finger to point, to ask for something? Yes/No

7. Does your child ever use his/ her index finger to point, to indicate interest in something? Yes/No

8. Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them? Yes/No

9. Does your child bring objects over to you (parent), to show you something? Yes/No

Section B (GP's or health visitor's observation):

i. During the appointment, has the child made eye contact with you? Yes/No

ii. Get the child's attention, then point across the room at an interesting object and say "Oh look! There's a (name a toy)!" Watch the child's face. Does the child look across to see what you are pointing at? Yes/No

iii. Get the child's attention, then give the child a miniature toy cup and teapot and ask, "Can you make a cup of tea?" Does the child pretend to pour out tea, drink it, etc? Yes/No

iv. Say to the child "Where's the light?", or "Show me the light". Does the child point with his/ her index finger at the light? Yes/No

v. Can the child build a tower of bricks? (If so, how many?) (Number of bricks.) Yes/No

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